In this blog, we are outlining the top five reasons Long Term Disability claims are denied.
Reason #1: Insufficient evidence to Support Disability
This is by far and away the rationale for denying most of the claims which this law office encounters. Claims representatives point to a lack of objective evidence and/or a lack of treatment recommendations commiserate with the claimed functionality deficits. As discussed in other blogs, these subjective vs. objective arguments can be difficult to overcome. There is case law in our favor, however. Subjective complaints of pain which are consistent in nature over time are to be considered objective in nature. This can be shown with consistent medical records. This is the easiest denial rationale for claims representatives to hide within, and the most difficult to overcome. Years of experience have taught us the exact tactics employed by the insurance companies to pigeonhole claims into these types of denial characterizations and how to overcome them.
Reason #2: Non-Compliance with Treatment
In order to receive benefits for Long Term Disability, the insurance provider is contractually entitled to proof of your disability. You must continuously submit updated medical records to prove that you continue to be disabled from working. If you do not submit these medical records, or receive the required treatment for your conditions, you are in violation of your obligation to do so and benefits may be terminated.
Reason #3: Change in Policy definition of Disabled
At some point, usually after Long Term Disability benefits have been payable for two (2) years, the definition of disabled in your policy may change to a standard that is harder to meet. These are called the Own Occupation and Any Occupation standards.
A common definition for Own Occupation would read something like: As a result of injury or sickness, you are unable to perform the material and substantial duties of your Own Occupation.
A common definition for Any Occupation would read something like: As a result of injury or sickness, you are unable to perform the material and substantial duties of Any Occupation for which you may reasonably be or become qualified by way of education, training or experience.
As you can imagine, the Any Occupation standard is a difficult standard to meet if you have any remaining functionality. The identified vocations that are suggested as potential jobs a claimant can perform are most usually sedentary in nature and do not pay a salary that most claimants would find acceptable.
Reason #4: Policy Exclusions
There are myriad of policy exclusions and limitations that limit the amount of Long Term Disability benefits to which you may be otherwise entitled. Conditions caused on the job (workers’ compensation) or by illegality are sometimes excluded.
In addition, there is a common limitation for mental/nervous conditions causing the disability. In such cases, benefits are not payable after two years. This limitation is incredibly frustrating because we have found that most of our physically disabled clients have some component of mental health issues as result and the genesis of the disability is purposefully confused.
Reason #5: Failure to Update/Communicate with Claims Representative
In order to prove and continue to prove your disability, you must communicate with your claims representative and send timely updates in your medical condition. This can feel incredibly overwhelming to a person whose entire life has been blown up by their disability. Keeping up with these demands can feel like your new, full-time occupation. Our firm handles all of the communication and medical updates for your claim for the life of your claim, not just when we get you approved for your Long Term Disability benefits. Give us a call at 407-839-0005 or, toll-free, 844-454-5995 to discuss more about your disability claim and how we can help.
